VHHC Patient Assessment Form

PATIENT INFORMATION
Title
Full Name and Surname

First NameLast Name
ID or Passport No
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
First Language
Second Language
Cell Phone Number
Format: +000 00 000 0000.
Home Phone Number
Format: +000 00 000 000.
Email
example@example.com
Gender
Home Address

Street Address

Street Address Line 2

CityRegion
EMERGENCY CONTACT INFORMATION
Title
Full Name and Surname

First NameLast Name
Email
example@example.com
Cell Phone Number
Format: +000 00 000 0000.
Home Phone Number
Format: +000 00 000 000.
Relationship
PERSON RESPONSIBLE FOR ACCOUNT
Full Name and Surname

First NameLast Name
Cell Phone Number
Format: +000 00 000 0000.
Email
example@example.com
PO Box Address

CityRegion

Postal / Zip Code
Main Member of Medical Aid
Main Member ID or Passport No
Medical Aid
Medical Aid Number
Medical Aid Option
PATIENT MEDICAL INFORMATION
Allergies
Medical Diagnosis
Medical History

Other
Other Conditions
List All Medication the patient takes
Previous Surgeries and Hospitalizations
CURRENT CARE ARRANGEMENTS
Who are the caretakers currently?

Other
How many hours a day are they with the patient?

Other
What are the duties of the current caregiver for the patient?
Family involvement of taking care of patient
What social or religious activities does the patient attend?
TYPE OF CARE NEEDED FOR THE PATIENT
What household duties is the patient still able to perform?

Other
How many hours a day are required for New/Additional Caregiver?

Other
Please select duties SPECIFIC TO PATIENT NEEDS

Other
NURSING CARE AVAILABLE
Quotation are made separately to Caregiver Services
COGNATIVE, BEHAVIORAL AND EMOTIONAL HEALTH
Orientation
Memory
Communication
Behaviour
Sleep pattern
Sleep pattern
Mood
DAILY LIVING NEEDS

Rows	Independant	Needs Assistance	Dependent
Feeding
Hygiene
Dressing
Grooming
Elimination

Appetite
Diet requirements
Aphagia
Food allergies

List
Fluid preferences
Alcohol intake

Other
Smoking

Quit
RISK AND SAFETY ASSESSMENT
Fall Risk
Any falls in the past 3 months?
Home safety hazards

Other
Pressure Sore Risk
Wandering Risk
Mobility

Other
Comments
SERVICE PROCESS AND PAYMENT
1. Patient assessment and personalized care plan done.

2. Quotation valid for 7 working days.

3. An invoice will be issued at the end of the contract/term/full payment received.

4. Acceptance of the quotation a 50% is payable.

5. Vital Health Home Care prepares and introduces a suitable caregiver to the family.

6. Families are never left without care - immediate replacements are arranged if necessary

7. To claim from your medical aid VHHC Invoice can be submitted.
CONSENT STATEMENT
I, hereby give my consent for Vital Health Home Care to provide Home Care services to the above mentioned patient.

Vital Health Home Care will maintain confidentiality of my personal and medical information, except as required by law or for emergency care.
PATIENT OR FAMILY REPRESENTATIVE

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PLEASE ATTACH MEDICAL AID CARD AND MAIN MEMBER PLUS PATIENT ID

Cancelof
Should be Empty:

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

PERSON RESPONSIBLE FOR ACCOUNT

PATIENT MEDICAL INFORMATION

CURRENT CARE ARRANGEMENTS

TYPE OF CARE NEEDED FOR THE PATIENT

NURSING CARE AVAILABLE

COGNATIVE, BEHAVIORAL AND EMOTIONAL HEALTH

DAILY LIVING NEEDS

RISK AND SAFETY ASSESSMENT

SERVICE PROCESS AND PAYMENT

CONSENT STATEMENT